›Arthrocentesis prioritized before antibiotics when stable
›Blood cultures before antibiotics when febrile or toxic
›Imaging for effusion localization when uncertain anatomy
Empiric antibiotics
›Empiric antibiotics
›Timing
›If septic shock then antibiotics immediately after cultures
›If stable then antibiotics after synovial fluid obtained
›Typical adult empiric coverage
›Vancomycin IV
›Initial dose 15 to 20 mg per kg
›Trough or AUC monitoring local protocol dependent
›Ceftriaxone IV
›2 g daily
›Gram negative risk or immunocompromised
›Cefepime IV
›2 g every 8 to 12 hours renal adjustment required
›Piperacillin tazobactam IV
›4.5 g every 6 to 8 hours renal adjustment required
›Gonococcal concern
›Ceftriaxone IV or IM
›1 g daily
›Doxycycline PO
›100 mg twice daily for 7 days when chlamydia not excluded
›Beta lactam anaphylaxis
›Vancomycin IV
›Aztreonam IV
›2 g every 8 hours renal adjustment required
Source control and consultation
›Source control and consultation
›Orthopedics consultation
›Suspected septic arthritis
›Prosthetic joint
›Infectious diseases consultation
›Bacteremia
›Unusual pathogens
›Operative washout triggers
›Hip involvement
›Shoulder involvement
›Failure of serial aspirations
Analgesia and supportive care
›Analgesia and supportive care
›Acetaminophen PO or IV
›1000 mg every 6 to 8 hours
›Maximum 3000 mg per day in many adults
›NSAID when appropriate
›Ibuprofen PO
›400 mg every 6 to 8 hours
›Contraindications
›CKD
›GI bleeding risk
›Opioid for severe pain
›Morphine IV
›0.05 mg per kg
›Repeat every 10 to 15 minutes to effect
Reassessment loop
›Reassessment loop
›Vitals every 30 to 60 minutes if ill appearing
›Pain and range of motion trend
›Perfusion and mental status trend
›Culture and Gram stain updates
17Disposition/dispo24
Admission criteria
›Admission criteria
›Suspected septic arthritis
›Positive Gram stain
›Synovial culture pending with high suspicion
›Sepsis physiology
›Immunocompromised state
ICU criteria
›ICU criteria
›Vasopressor requirement
›Lactate persistently elevated
›Worsening respiratory status
›Altered mental status
Transfer criteria
›Transfer criteria
›Need for urgent orthopedic surgery not available
›Pediatric hip suspected septic arthritis
›Prosthetic joint infection requiring specialty service
Discharge criteria when septic arthritis ruled out
›Discharge criteria when septic arthritis ruled out
›Alternative diagnosis established
›Stable vital signs
›Pain controlled on oral regimen
›Reliable follow up within 24 to 72 hours
Observation pathway criteria
›Observation pathway criteria
›Low suspicion after aspiration and labs
›Pending cultures with close reassessment plan
›No systemic illness
18Discharge Instructions/di20
Copy discharge instructions
›Copy discharge instructions
›Today you were evaluated for joint pain and swelling
›A serious joint infection can worsen quickly and can damage the joint
›Return to the emergency department now if any of the following occur
›Fever
›Increasing pain
›Increasing swelling
›New redness spreading
›New inability to walk or use the joint
›New weakness or numbness
›New confusion
›Medications
›Take pain medicines exactly as prescribed
›Avoid NSAIDs if you were told you have kidney disease or stomach bleeding risk
›Activity
›Rest the joint
›Avoid weight bearing until symptoms improve unless told otherwise
›Follow up
›Follow up with your clinician within 24 to 72 hours
›If cultures were sent you may be contacted with results and treatment changes
19References/r6
Guidelines and key sources
›Guidelines and key sources
›Infectious Diseases Society of America guideline for MRSA infections 2011
›American Academy of Orthopaedic Surgeons clinical practice guidance for diagnosis and management of periprosthetic joint infection 2019
›European Bone and Joint Infection Society guidance on septic arthritis in native joints 2023
›Centers for Disease Control and Prevention sexually transmitted infections treatment guidelines 2024
›American College of Rheumatology gout management guideline 2020
Evidence & Review
Reviewed by SymptomDx Medical Team·Last reviewed
SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.